30909 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING•ELECTRICAL PERMIT NO. ^O /N 0
BUILDING DIVISION - APPLICATION/PERMIT PLUMBLNG.MECHANICAL 3 VM
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRFSSt SANITARYNO. APPLICATIONSUBMITTALDATI
w c� 6014P. _g.
OW f/� HONE" CO &OR'SNA IC NO:
1f , \ S N/C CONTROL#
CHITE /ENG EER: LIC AD(�tE�S: � ❑
r U� I
Co ACC PHONE: BUILDING PERMIT INFO
1-�_ I )nf�� a..E y/ ❑ Consultant Fees Paid by Applicant(Initial) t BLDG ELECT PLUMB MECH
�I c /Y/G� EEr ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby of ino that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
with Section TXXB of Division 3 of the Business and Professions Code,and my license is -RESIDENTIAL'
D O PERMIT ISSUANCE - ----
LV in fullforce and of t. �1 ISFDWL ❑KITCHEN REMODEL
FaF..0 Licenu Clazs LIC.N OC APPLIANCES-RFSIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
en66 Da¢ Comracron GI
ARCHITECTS DECLARATION PANELS ❑MULTIUNIT Cl STRUCTURAL
O Z�Z 1 understand my pions shall be used as public records MODIFICATION
UP'O 2(p AMPS
F W 1- Lice. d P ofessional El INTERIOR ❑CHIMNEY REPAIR
201-1000AMPS IMPROVEMENT
s .OWNER-BUILDER DECLARATION OVER["AMPS C1 BATH REMOpCVRF.PAIR ❑OE.170 (TION
6O6 O I hereby a116.that 1 nm exempt from the Conmactors License Law for the ('1j��aT� JJ
pe 3 following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL OTHER
f{sUlµO which requires a permit to construct,vhcr,impmve,demolish,or repair any structure AAA ,
IFFES� 4 prior to its issuance,also requires the applicant for such permit o file v signed statement SPECIAL CIRCUITIMISC. ^O0�
F, y that he is licensed pursuant to the provisions of the Contractor's license Law(Chapter 9 ter• wzzff
44CC11 �� (commencing with Section 7000)of Division 3 of the Hurstess and Professions Code)or TEMP.MGfER OR POLE INST. COMMER
6 e ee thvt he h exempt therefrom vel the basis for the alleged esentEnnn.Any violetinn of C1 NEW BLDG/ADDRION [I DEMOLITION
4• Section applicant 5 by any applicant for a permitsubjects the applicano a civil penalty of POWER DEVICES ❑
Mm TE ❑ CE
NANT FOODy not more Nan five hundred dollars($50% IMPROVEMENT
aQ ❑ SWIMMING POOL ELECTRIC
I,asownerof We progeny,ear my employees with wegex us their vele compensation,
will do the work,and the suucm a is not intended oco00
Dcred for .In(Son 7( ,Business ❑OTHER
W and Professions Code:The Contractors License Law does nm apply to an owner of OUTLETS-SWITCHES-FIXTURES �
63^ property who but Ids or impmve%thereon,and who does such work himself or through
his own employees,provided that such improvemenu are not intended or offered for NEW RESIDENTIALELECTR SQ ff.
sale.If,however,the building or impruvemem is sold comn one yearnfcompletionJM1e SQ,IT,FLOOR AREA 5/SQ.FT.
owner-builder will have the burden of proving that he did not build or improve for par
pose rf side.).
'(]1,as owner of the property,am exclusively contracting with licensed contractors 4) AL'
cotrarocl the project(Sec.Tota,Business and Professions Cede:)The Convectors Li-
cerse Law does not apply to an owner of property who builds or improves themon.ad QTY, PLUMBING PERMIT FEE -.
who contracts for such projects with a contractors)licensed pursuant to the Contmi
License Law. - PERMIT ISSUANCE
❑1 rear exempt under Sac. .B&P C for this reason
Owner Dam ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE
1 hereby affirm under Penalty of perjury one of the following deelamtions:
I haveand will maintain a Certificate of Conaenuo self-insum for Worker's Compete DRAINS-FLOOR,ROOF,AREA.GOND.
on,as provided for by Section 3700 of the Labor Code,for the performance of the STORIES TYPE CONSTRUCTION
work for which this permit is issued. FIXTURFS-PER TRAP
1hove vad will maintain Workers Compensation Insurance,as required by Section
pofibe Labor Cmle,hmtheperfcamanceofthe work forwhich this permit is issued. GAS-EFA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Wmr Compensation Insurance carrier and Policy. 'un I
CPolicy N..2 GAS-FA.SYSTEM-OVER 4(PA)
CtIurrier:
TIFlCATF,OF EXEMPTION FROM WO RST
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION PIT PS
(This section need nor be completed if the permit is fnrooe hundred dollars(Sled( GREASETRAP
or kssJ PLANCHET '
I cenify than in rhe performance of the work for which his permit is issued,l shall SEWER-SANITARY-STORM EA.200 It.
nm employ any person in any manner an as ro Mcome subjecuo the Workers'Compcn-
ti
EN Y
Z a. aws ofClifois.Date
O Applicant WATER HLATPR WVPELECRz GR ING
NOTICETO APPLICANT.If,after making F
E
this Certificate of Exemption,you should WATER SYSTRMTREKHNG S
1"s become subject to The Worker's Computation provisions of the Labor Code,you must
forthwith comply with such provision or this permit shall be deemed revoked. WATER SERVICE
CONSTRUCTION LENDINGAGENCY NEW RBSIDENTIAI.PLMB. SQ PAID Date Nccei
U 0 (hereby affirm that there iaeconswction lending agency frnbe perfommnce of
Wr Pthe work for which this perch is issued(Sec.3097,Civ.C.)
(sender's Name
WLenders Address TO L.
y 1 certify that I have read this application and stare Choi rhe above information is qBUMDINOME ,EE .U] correct.I.gree m comply with all city vnd county ordinances and state laws relating m QTY, MECHANICAL PERMIT V 7 building construction,and hereby authorize reptexenmtives ofthis city to enter upon the Eabove-mentioned property for inspection purposes.(We)agree msave,indemnify and keep harmless the City ofCupertino against PL+RMIT ISSUANCE: EF.liabilities,judgments,costs and experscs which may in any way aceme against said City ALTER OR ADD TO MUCH.in consequence of the grunting of this permit. FEEAPPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT CFO HUDW CFM) BSOURCE REGULATIONS. AIR HANDLING UNIT(OVER 10,00)CFM) fIG TAX
Signature of ApplicardConumemr Date EXHAUST HOOD(W/DUC) HOUSINGMITIGA NFEE
HAZARDOUS MATERIALS DISCLOSURE,
Will to applicant or future building comparistore nor handle hazardous mmerivl I IEAT'1NO UNIT TO 100.010 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)^ HEATING UNIT(OVER IM."BTU)
❑Yee ❑No VENTILATION FAN(SINGLE RESID) PAID
Date Receipt is
Will the applicant or future building occupant use equipment or devices which BOILER-COMP(3NP OR IOO,g10 BTU)
It It nolkus sir commands,as defined by the Bay Amu Air Quality Management TOTAL:
strict? BOILER-COMP(OVER PonBTU)
❑Yes ❑No
AIR CONDITIONER
- (have read the transition materiels requirtmrnu uMer CbvPtei6.95 of Ne Cali- ISSUANCE DATE //JJ
toads Health&Safety Code,Sections 25505.25533 and 25534.1 understand Nm if the NEW RESIDENTIAL MECH. SQ.FT. q P
building does not currently have a tenant,than it is my responsibility la unify rhe occupant o
of the ire rs wbi an Ilii tpntxtoiuuvnceofa Cenifrcat1eo�cuepaecy. t
OwnerOwner tin ore agar a agent t r - v�Ar7, TOTAL: ISSUED BY: ao"- `c
OFFICE